David A. Sasso, MD, MPH

by David A. Sasso, MD, MPH, for the Group for the Advancement of Psychiatry Committee on the Arts and Humanities.

August has long been known as the therapist’s holiday, the month when psychoanalysts traditionally pause intensive work for time away from the office. There are countless references to the difficulties patients may encounter during this late summer month, caricatured to hilarious proportions in the 1991 movie 

Here is a look at a historic August vacation interrupted and some lessons for the unprecedented predicament of psychotherapy in the age of a pandemic.

On August 26, 1910, 2 men were seen taking a long stroll through the streets of Leiden in Holland. Both in their early 50s, one would go on to live another 29 years, and one would be dead by the following May. From a distance, perhaps they appeared to be old friends or colleagues, engrossed in deep conversation. Locals may have guessed that one was seeking counsel from the other and in some distress. While the name of the town, Leiden, is said to come from a Germanic word meaning “canal” or “river,” the German word 

 also means to suffer or to endure. The 2 participants in this Friday afternoon promenade were in fact Gustav Mahler and Sigmund Freud. And far more than a casual chat, it was a single extended 4-hour therapy session: the brief psychoanalysis of Mahler by Freud.

Many have written about the details of the encounter. Mahler had been working on his never completed 10th symphony and had become greatly distressed that his wife, Alma, was having an affair with architect Walter Gropius (whom Alma would go on to marry 4 years after Mahler’s death). Freud made several interpretations that astounded Mahler, including surmising the name of Mahler’s mother and identifying a “mother fixation,” suggesting that Mahler was “seeking his mother in every woman.”

 This analysis gave Mahler some relief and helped him to connect 2 childhood memories: a scene of conflict between his parents and hearing a folk-song played on a hurdy-gurdy in the street. Freud later recalled, “Mahler thought from this moment on, deep tragedy and superficial entertainment were tied together indissolubly in his soul and that one mood was inevitably tied to the other.”

Leaving aside the content of the session, the context is instructive. Mahler had previously made and broken 2 appointments with Freud earlier that summer, and when he requested a third, the only solution was to meet near the spot in southern Holland where Freud was spending the month. This was inconvenient for Freud; not only was he on vacation, but he also was exhausted by the recent International Congress of Psychoanalysis at Nuremberg and was recovering from a bout of colitis.

 He was also far from his office, so the meeting had to be conducted on foot. Freud later described details of his session with Mahler in now-jarring disclosures to his analysand Maria Bonaparte some 15 years later. Noting his departure from typical August holiday norms, he confessed, “I made an exception in receiving someone during my vacation, but a man like Mahler . . .”

This snapshot of Freud runs counter to how many view him and his theories today. There are some who imagine Freud to have been rigid in his thinking and his psychoanalytic frame unbending in its approach. That may have been the advice he gave to others, but, for better or for worse, he often broke his own rules, as in this case: seeing a patient in the middle of his vacation, conducting therapy outside the office, for any local passersby to see. In many instances, Freud’s behavior with his patients would not be considered Freudian at all in the 

As we reconcile the challenges facing the practice of psychotherapy today with myriad restrictions necessary to stem the spread of the novel coronavirus, there are lessons to draw from the man whose legacy, unfortunately, is sometimes ridiculed as inflexible, rule-bound, and out-of-date.

Before the pandemic, many psychiatrists would have dismissed the possibility of effective psychotherapy occurring through video. Yet, by necessity, the field has adapted and learned to shed the trappings and comforts of carefully decorated offices, couches, and armchairs, and distance from homes, pets, and children. Just as Freud made do with a set of circumstances that prevented him from working in his accustomed way, today’s psychiatrists can take a lesson. The safety and boundaries of the enclosed office, with a therapeutic frame sealed off from the outside world are, paradoxically, no longer safe, so we have turned to virtual settings.

As we slowly and cautiously work toward a practice where space can be shared between therapist and patient, perhaps Freud’s “walking cure” can be enlightening. Sessions out of doors may still seem as hard to imagine as video sessions were for many therapists just months ago. But perhaps in the coming months they may offer a starting point to think about reconnecting in person with our patients in a safer shared physical space than the office. Issues around confidentiality, admittedly, will not be easy to resolve. How will we create, flexibly but thoughtfully, new frames in order to maintain the holding environment and expectation of privacy that makes the consulting room sacred?

As you ponder these questions, if you have never listened to the first movement of Mahler’s painfully gorgeous and unfinished Symphony No. 10, find a moment to do so this month in honor of a peripatetic therapy session that took place 110 years ago.

is a child and adolescent psychiatrist and musician in New Haven, CT, where he serves as Assistant Clinical Professor in the Child Study Center at the Yale University School of Medicine.

Members of the Group for the Advancement of Psychiatry Committee on the Arts & Humanities: David Sasso, MD, MPH (Committee Chair); Anish Ranjan Dube, MD, MPH, Volunteer Clinical Faculty, University of California, Irvine; Donald Fidler, MD, FRCP-I, Professor Emeritus, West Virginia University; Andrew Lustbader, MD, Associate Clinical Professor in the Child Study Center, Yale University School of Medicine; Chris Snowdy, MD, Program Director, USC Child and Adolescent Psychiatry Fellowship; Kenneth J. Weiss, MD, Robert L. Sadoff Clinical Professor of Forensic Psychiatry, Perelman School of Medicine, University of Pennsylvania, andHelena Winston, MD, Assistant Professor, Department of Psychiatry, University of Colorado.

2. Jones, Das Leben und Werk von Sigmund Freud. In: Floros C. 

 New Haven: Yale University Press; 2004: p. 208.

4. Maria Bonaparte, unpublished diary. In: Feder S. 

The advantages of Freud's technique as shown in his analysis of the Rat Man

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As we slowly and cautiously work toward a practice where space can be shared between therapist and patient, perhaps Freud’s “walking cure” can be enlightening. 

The Walking Cure

A psychiatry resident meets regularly for coffee with a friend studying architecture. They begin a dialogue on what makes for a healing environment on a mental health ward. An ER psychiatrist listens to Mahler’s Second Symphony after a particularly difficult shift fraught with violent outbursts by a couple of distressed patients. A supervisor in psychotherapy asks her residents if they would like to read and discuss a poem about death together instead of pursuing the scheduled talk on bereavement. They choose the poem.

If you were to ask these physicians what role the arts and medical 

 played in their working lives, they might answer they were simply doing something they liked. But if you were to press them to go deeper, it would become apparent they were creating a space for creative reflection-for thinking and feeling “outside the [medical] box.”

Doctors at all levels of experience struggle at times to find meaning in their work. With sub-sub-specialization, dwindling resources, insurance squabbles, and 

, physicians yearn for deeper connection with peers and patients.

For some, psychiatry is about receptors in the brain, but for many that is not enough. The brain is also the locus of the mind, and the human mind insists on making 

. Evidence-based medicine has fallen short of its promise and has taken the focus away from subjective experience in working with patients. Instinct, intuition, and imagination cannot easily be measured and, perhaps for this reason, are not typically seen as “belonging” in the science of medicine. Ironically, as psychiatry has sought out credibility within medicine, it has placed less importance on narrative competence or the ability to work with and interpret patient stories. Even more ironic, the field of narrative medicine appears to have emerged and found more welcome in other medical specialties than in psychiatry.

The health humanities offer a formidable remedy for what ails contemporary psychiatry.

Until fairly recently, “medical humanists” in psychiatry have worked in splendid isolation within their communities and even in their academic faculties, often because their fascinations and pursuits seemed “fluffy” to their fellow practitioners. Residents often viewed their own creative pursuits as “add-ons” or completely dispensable.

Why did a faculty member take students to the art gallery to work on their visual literacy and perception of non-verbal cues? Why did a psychiatrist write a paper about the history of wine? Why did a psychiatry fellow invite an actor to help trainees be more physically embodied and fully present when seeing patients? Why has a child psychiatry resident started exploring bibliotherapy and comics with children or begun to use music as a way to reach non-verbal patients? These are questions that should be considered integral to conversations regarding what makes a well-rounded psychiatrist.

We* see the value in such unexpected unconventional undertakings. These pursuits not only place a high value on 

 and the role of aesthetics in both personal and professional life, they enhance many of the competencies expected from trainees-communication, professionalism, reflective capacity, and collaboration. An artistic or intellectual passion can provide a new focus for appreciating and recharging one’s daily work and learning. Creativity should not be seen as “optional” in psychiatry. Rather, it helps us to approach clinical problems in new ways, allows us to pull together disparate ideas, and sustains us in the face of uncertainty

The health humanities offer a formidable remedy for what ails contemporary psychiatry because it expressly explores the human side of medicine. Increasingly, research demonstrates that exposure to literature, music, the fine arts, theology, medical history, philosophy, critical studies, and anthropology broadens a resident’s cultural competence and encourages the linking of both cognitive and affective approaches to the physician’s task. The arts and humanities also validate the importance of the doctor’s subjective, personal experience with a patient, which, balanced with caution against stereotyped judgment, has long been a critical source of clinical information in psychiatry.

Reflective practitioners take better care of their patients 

 themselves. Ongoing dialogue with colleagues from the arts and sciences both complements and stretches one’s views of health, disease, and healing. These conversations can help challenge assumptions and illuminate blind spots, while inviting us to articulate why we do what we do. Poets, musicians, and artists have been contemplating suffering for longer than psychiatrists and have much to teach. They also give permission to rediscover the Art in what we do and to fully imagine what makes our work beautiful. If psychiatry is about the brain, why not use both sides of it?

*The members of the Committee on Arts and Humanities at the

 are David Sasso, MD (Chair), Aparna Atluru, MD, (fellow), John Cahill, MD, Joseph Carmody, MD, Anish Dube, MD, Don Fidler, MD, Alan Gruenberg, MD, Andrew Lustbader, MD, Allan Peterkin, MD, Anna Skorzewska, MD, John Tamerin, MD, and Ken Weiss, MD.

Dr. Peterkin is Professor of Psychiatry and Family Medicine and Director of the Program in Health, Arts and Humanities, University of Toronto. Dr. Sasso is Assistant Clinical Professor at the Yale Child Study Center, New Haven, Connecticut and Medical Director, Child Guidance Center of Mid-Fairfield County, Norwalk, Connecticut. Dr. Skorzewska is Assistant Professor at the University of Toronto Faculty of Medicine and Director of the Psychiatric Intensive Care Unit at University Health Network in Toronto.

Creativity should not be seen as “optional” in psychiatry. Rather, it helps us to approach clinical problems in new ways. 

Author | David A. Sasso, MD, MPH

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The Walking Cure

The Arts and Humanities in Psychiatry . . . A Debut